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2007;9:171176

Risk management

Risk management Planned

vaginal breech delivery: should
this be the mode of choice?
Author Basil van Iddekinge

Key content:

The risks of serious early perinatal morbidity and mortality are three times higher for planned
vaginal breech delivery than for elective caesarean section.
Because morbidity and mortality are relatively low, a large number of caesarean sections needs
to be performed to avoid a single adverse event.
External cephalic version appears to be a safe procedure that can halve the number of breech
presentations but the procedure is not risk-free.
Four guidelines or directives are outlined but need to be adapted to the setting in which they
are applied.
Planned vaginal breech delivery is an acceptable choice to offer, provided strict protocols are
followed.

Learning objectives:

To gain an awareness of the risk factors and benefits of external cephalic version.
To gain an awareness of the short and long-term risk factors and benefits to the mother and
child of planned vaginal breech delivery compared with elective caesarean section.
To be able to manage breech presentation at term in different clinical and in differently
resourced settings.

Ethical issues:

Can planned vaginal breech delivery be justified?

How can expertise in vaginal breech delivery be learned or taught if a policy of elective
caesarean section is implemented?
How can we obtain genuine informed consent when there are so many areas of uncertainty for
degree of risk and benefit?

Keywords caesarean section / consent / external cephalic version / mode of delivery /

risk / vaginal breech delivery
Please cite this article as: van Iddekinge B. Planned vaginal breech delivery: should this be the mode of choice? The Obstetrician & Gynaecologist 2007;9:171176.

Author details
Basil van Iddekinge

MSc FCOG(SA) FRCOG

FRANZCOG

Retired Associate Professor of Obstetrics

and Gynaecology
Formerly at:
Department of Obstetrics and Gynaecology
Johannesburg Hospital and the University of
the Witwatersrand, Johannesburg

South Africa
Email: vaniddekinge.b@bigpond.com
(corresponding author)

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Introduction
Following publication in 2000 of the Term Breech
Trial there has been a major shift toward elective
caesarean section for breech delivery at term.1 This
is mainly because of the finding that neonatal
mortality and serious morbidity were 5% in the
planned vaginal birth group compared with 1.6%
in the planned elective caesarean section group.
Although the trial clearly outlines and quantifies
the risk, Glezerman2 is adamant that concerns
regarding the design and methods of the trial are
sufficiently serious to justify them withdrawing
their recommendations. However, there is no
prospect of repeating such a large randomised
controlled trial to address any of these deficiencies
and obstetricians are going to have to decide which
method of delivery to offer women. The available
information that we can reasonably give to women
will have to be sufficient to enable an informed
decision to be made on the method of delivery.
There have recently been three large populationbased comparative studies from the Netherlands,3
Sweden4 and Denmark:5 all confirm improved
perinatal morbidity and mortality with elective
caesarean section. However, in a more recent
observational prospective study in France and
Belgium, the neonatal mortality and morbidity for
vaginal breech delivery was 1.6% this is much lower
than in the Term Breech Trial and not significantly
different from the caesarean section group.1,6
The risk versus benefit aspect needs to be brought
into perspective for all obstetric practitioners.
Experience, resources and working conditions need
to be taken into account. Rietberg et al.3 calculated
that 175 caesarean sections are needed to avoid one
fetal death, while Hofmeyr and Hannah7 suggested
that 29 caesarean sections would avoid one case of
serious neonatal morbidity or death. There will also,
no doubt, be an increase in potential problems, such
as uterine scar dehiscence and placenta praevia
accreta, in future pregnancies: these are life
threatening to mother and baby. In the Rietberg et al.3
study it was estimated that, for every infant saved by a
caesarean section, one woman would experience a
uterine rupture during a subsequent pregnancy.
In a large epidemiological study, Smith et al.8
showed an absolute risk of unexplained stillbirth at
or after 39 weeks of gestation of 1.1 per 1 000
women who had a previous caesarean section,
compared with 0.5 per 1 000 women who had not.
However unlikely such complications are deemed,
they must be brought to the attention of the parents
when discussing method of delivery and informed
consent. In the United Kingdom, 11% of all
caesarean sections are now performed for breech
presentation, despite guidelines that recommend
external cephalic version (ECV).9
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In poorly-resourced health services the benefit of

elective caesarean section becomes even more
dubious. In low-resource settings, caesarean section
is often performed by relatively inexperienced
operators and anaesthetists. This increases the risk
to the mother, which may be even greater in the
future because of lack of access to facilities for
caesarean section in following pregnancies. While
clinicians, and the societies who represent them,
have drawn up guidelines that are reasonable and
sustainable for the conditions in which they
practise, they may not be appropriate in other
countries.
In short, one should always ask what one would
choose for oneself or ones family in this situation.

Established guidelines and

directives
Royal College of Obstetricians and Gynaecologists
Green-top Guideline No. 20
In their Green-top Guideline No. 20 (April 2001),
the Royal College of Obstetricians and
Gynaecologists (RCOG) recommended offering all
women with an uncomplicated breech presentation
an external cephalic version (ECV) at term
(3742 weeks), provided there were no
contraindications.10 If this is not performed, or is
unsuccessful, an elective caesarean section at term
should be offered. Two important points are
highlighted in the guideline:
It remains important that clinicians and hospitals
are prepared for vaginal breech delivery.
Any woman who gives birth to a breech vaginally
should be cared for by an attendant with suitable
experience.
Green-top Guidelines Nos. 20a and 20b
In December 2006, Guideline No. 20 was updated
and divided into two parts,11,12 addressing ECV and
breech presentation separately (parts 20a and 20b,
respectively) and increasing the total number of
pages from 9 to 21. This reflects the complex nature
of the guideline and that it outlines a less rigid
approach to mandatory elective caesarean section,
which followed the Term Breech Trial.1 There is
more detailed information on the benefits and risks
of planned caesarean section versus planned
vaginal breech delivery and on counselling women
with a breech presentation. Benefits, risks and the
role of ECV are discussed in more detail.
Other important issues addressed are:

Information that should be given about risk to

mother and baby in the short and long term for

each method of delivery.
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Royal College of Obstetricians and Gynaecologists1012

2007;9:171176

Green-top Guideline No. 20 (2001)

Recommended offering all women with uncomplicated breech
presentation an external cephalic version (ECV) at term
(3742 weeks), provided there were no contraindications. If not
performed, or unsuccessful, elective caesarean section at term
should be offered.

Risk management

Box 1

A summary of guideline and

directive recommendations on
breech delivery

It is still important that clinicians and hospitals are prepared for

vaginal breech delivery.
Recommended that any woman delivering a breech presentation
vaginally should be cared for by an attendant with suitable
experience.
Green-top Guidelines Nos. 20a and 20b (2006)
More information on benefits, risks and the role of ECV.
A less rigid approach to elective caesarean section.
More information on short and long-term benefits and risks of
modes of planned delivery and on advising women of them. Safety
factors and details of intrapartum management of breech
presentation and delivery.
Training, counselling and documentation highlighted.
American College of Obstetricians and Gynecologists13

Planned vaginal breech delivery may be reasonable under hospitalspecific protocol guidelines.
Documented, informed consent, clearly outlining the increased
short-term serious risk to the infant, is a prerequisite.

Royal Australian and New Zealand College of

Obstetricians and Gynaecologists15

States that the level of risk is higher in planned vaginal breech

delivery than in elective caesarean section but does not exclude
it as an option.
Maternal preference should be considered.

National Institute for Health and Clinical Excellence16

Recommends ECV for breech presentation at 36 weeks of gestation

and elective caesarean section if the procedure is declined or fails.

Details of intrapartum management of breech

presentation and delivery.
Training, skill and experience of the intrapartum
attendant.
The need for clear documentation, including

details of counselling and the identity of all those

involved in the procedures.

American College of Obstetricians and

Gynecologists
Through their Committee on Obstetric Practice,
the American College of Obstetricians and
Gynecologists (ACOG) issued a Committee
opinion paper on Mode of term singleton breech
delivery in 2006.13 This is not as emphatic about
elective caesarean section as the earlier RCOG
guideline and indicates that planned vaginal breech
delivery may be reasonable under hospital-specific
protocol guidelines. Documented, informed
consent, clearly outlining the increased short-term
serious risk to the infant, is a prerequisite. To assist
with this, the ACOG has produced an excellent
patient information sheet, which can be
downloaded from their website.14 This can be
amended to suit ones own practice and will assist
with informed consent issues related to ECV and
vaginal breech delivery.
Royal Australian and New Zealand College of
Obstetricians and Gynaecologists
In March 2005 the Royal Australian and New
Zealand College of Obstetricians and
Gynaecologists (RANZCOG) issued a formal
statement concerning breech delivery at term.15
This can be viewed on their website. In essence, it
2007 Royal College of Obstetricians and Gynaecologists

indicates that the level of risk is higher in planned

vaginal breech delivery than in elective caesarean
section but does not exclude it as an option. The
statement outlines factors that reduce the risk of
vaginal delivery and also points out the risk in
subsequent pregnancies after caesarean section,
including uterine scar rupture and placenta praevia
accreta. The final point made is that maternal
preference should also be considered.
National Institute for Health and Clinical
Excellence
In their 2003 Clinical Guideline,16 the National
Institute for Health and Clinical Excellence (NICE)
recommend ECV for breech presentation at
36 weeks of gestation and elective caesarean section
if the procedure is declined or fails.
The difficulty in setting rigid guidelines is clearly
apparent. Clinicians, in consultation with their
patients, must make the final decisions regarding
ECV as well as method of delivery.

Pros and cons of external

cephalic version, planned
vaginal breech delivery and
elective caesarean section
External cephalic version
In a Cochrane review,17 ECV appeared to be a safe
and effective way of reducing the number of
elective caesarean sections for breech presentation
but there was not enough evidence to quantify
serious complications. Large observational studies
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suggest that these are uncommon.18 In this review

of 44 studies, which included 7 377 participants,
transient abnormal heart rate patterns occurred in
5.7% of cases, with persistent abnormality in
0.37%. Other complications included vaginal
bleeding (0.47%), placental abruption (0.12%) and
emergency caesarean section (0.43%). Perinatal
mortality was 0.16% but this needs to be kept in
perspective with an expected fetal loss rate of 0.6%
between 36 and 42 weeks of gestation in a low-risk
population.

in place. A very good training video can be found at

the World Health Organization (WHO)
Reproductive Health Library.24

It is also clear that ECV should not be offered if

ready access to emergency caesarean section is not
available. Busy units may not be able to offer this
assurance and this may be a reason why the
implementation of ECV is inconsistent.19 If needed,
emergency caesarean section may be performed
more quickly under general than epidural
anaesthesia but this would require rapid sequence
induction. It seems unreasonable to fast all women
undergoing ECV.

In the 2-year follow-up study25 of the children of

the women enrolled in the Term Breech Trial, the
primary outcomes of death and
neurodevelopmental delay at 2 years of age were
similar between the two groups. The smaller
number of perinatal deaths with planned caesarean
section was balanced by a greater number of babies
with neurodevelopmental delay. This was
unexpected as there had been fewer babies with
severe perinatal morbidity in the planned caesarean
section group. While inherent neurological
abnormality may be the reason for persistent
breech presentation, randomisation should have
excluded this possible bias.

The relative and absolute contraindications to ECV

are outlined in a review by Green and Walkinshaw.20
Success rates in the review varied between 5080%.
The validity of the contraindications has not yet
been tested in randomised controlled studies. Fetal
heart monitoring is recommended as bradycardia
occurs frequently and, if persistent, urgent delivery
may be required.21 Use of tocolytic agents improves
the success rate of ECV and, at the doses required,
they have few risks or side effects.22
In a case controlled study23 the caesarean section
rate was almost three times higher in a group of
279 women who had undergone successful ECV
compared with controls who had spontaneous
cephalic presentations (23.3% compared with
9.4%, respectively). The indications for caesarean
section were mainly: failed induction of labour,
fetal distress and failure to progress in labour.
Informed consent for ECV is extremely difficult, as
the risks to both mother and fetus are small but it
would be unreasonable not to ensure awareness of
the risk of emergency caesarean section and the
small possibility of perinatal death.
If ECV fails or the procedure is declined, the
choice of planned vaginal breech delivery or
elective caesarean section must be discussed. The
two issues of ECV and caesarean section are
closely linked. Counselling and consent issues,
therefore, need to be initiated by the 36-week visit
to give the woman sufficient time to make an
informed decision.
Training in ECV is much simpler than for vaginal
breech delivery and it should be included in the
formal training programme. Methods and
protocols for performing the procedure should be
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Planned vaginal breech delivery

Information regarding risk to the fetus with vaginal
breech delivery has been partly quantified by the
Term Breech Trial. However, future risk of
childbirth after caesarean section, pelvic floor
damage and urinary or other incontinence issues
after vaginal delivery have not been considered.

Planned vaginal delivery thus seems a reasonable

alternative to elective caesarean section provided
that strict hospital-based protocols are followed,
patient selection is carefully supervised and
sufficient personnel trained in vaginal breech
delivery are available for the delivery. However,
training in assessment and delivery of breech
presentations must be continued, even if much of it
is by simulation with models and video
demonstrations. A very good video demonstration
of vaginal breech delivery can be found in the WHO
Reproductive Health Library on their website.24
Training with models and videos must be backed
up by observation of experienced obstetricians and
closely supervised application in practice. These
skills need to be assessed as part of the training
programme for registrars. Workshops should be
offered for those who are not confident in assessing
and performing vaginal breech delivery.
Consultants should be available to advise and assist
junior staff with vaginal breech assessment, method
and timing of delivery.
Although both sets of RCOG Green-top guidelines
recommend that a suitably experienced person be
available for a vaginal breech delivery, there is no
clear definition of the skills and requirements of
such a person.
In each unit where vaginal breech delivery is
offered, clear protocols and contact personnel need
to be documented and continuously audited to
help avoid poor outcomes or medicolegal issues.
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Women and their partners need to be counselled

as to the availability of a suitably experienced
person if they request a vaginal breech delivery. If
they are not informed of this it may create the
basis for litigation, should the outcome be poor.
Alternatively, they may feel that elective caesarean
section is a safer option in circumstances where
appropriate staff members are not always
available.
Breech deliveries that do occur may, of course, be
under unfavourable circumstances, including
preterm or advanced labour, where it may not be
possible to offer caesarean section. Clearly,
complications are more likely to occur, especially if
the breech delivery is attended by inexperienced
personnel.
Elective caesarean section
Since the Term Breech Trial,1 elective caesarean
section at term has been adopted in many parts of
the world as the proven delivery method of choice
for breech presentation at term. Although
criticisms have been raised about the trial, subanalysis of groups within the trial has resolved
many of them, particularly with regard to the shortterm fetal outcome. The 2-year
neurodevelopmental follow-up is of some concern,
as is the risk to the mother in future pregnancies,
while the latter has not yet been addressed.
In a secondary analysis of the Term Breech Trial,26
adverse perinatal outcomes were lowest when
prelabour caesarean section was performed and
increased with women in labour. Independent risk
factors were: labour augmentation, birthweight
below 2.8 kg and a long interval between pushing
and delivery. The presence of an experienced
clinician during vaginal delivery decreased the
risk.
A study from Ireland27 of primigravid women
showed that, although the chance of having a
breech presentation in the next pregnancy was
increased, the overall caesarean section rate was not
greater than in women who had had a caesarean
section for other indications with cephalic
presentation in their first pregnancy.
Subsequent occurrence of scar dehiscence and
placenta praevia accreta are life-threatening
complications and informed consent should
include them, even though they may occur in fewer
than 1% of cases.
It is wise to document all the risks inherent to either
method of delivery and to give women an
information sheet outlining these risks, as they may
not remember them all. This will help to inform
partners or family who may be involved in the
decision-making process.
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Risk management

If the ACOG patient information document is

chosen, modification of the information to include
risks in future pregnancies after caesarean section
and risk of pelvic floor damage after vaginal
delivery is advisable.14

Consent and medicolegal

issues
As with all forms of consent, a woman needs to
understand the nature of the procedure
(competence) and have sufficient information to
reach a decision to agree or refuse the procedure
(knowledge). Lastly, she must be willing to undergo
the procedure with the information she has been
given (voluntariness). This informed consent must
be clearly and carefully documented.
Following the view of Eddy28 (which applies to
English law), if the Bolam test29 is applied, we might
assume that ECV can be offered in accordance with
accepted medical practice. However, if we fail to
warn of all possible risks of the procedure and a
complication occurs, we could be found to have
been negligent.
In general terms, women should know about any
serious risk that can occur in more than 1% of
cases. Since the Bolitho case,30 however, this may
not be sufficient for risk of serious injury or death
where it may be left for the courts to decide the
matter. In-depth discussion of benefits and risks
should help avoid litigation but accepted medical
practice on its own is not sufficient.
The decreased risk to the fetus may sway a woman
to choose planned caesarean section on this basis
alone. However, should a vaginal breech delivery
become necessary through unforeseen
circumstances, might she not have grounds for
litigation? Clearly, this would depend on the
specific circumstances and the accuracy of the
information that had been provided about risks of
preterm labour, timing of the elective caesarean
section and facilities available to accommodate the
procedure. Should she choose to have a vaginal
delivery after the information has been given,
optimal conditions for a vaginal breech delivery, in
line with the guidelines, and the presence of a
person with sufficient experience to perform the
delivery will need to be in place. In many clinical
settings this would be difficult to achieve and unless
this is made clear to the woman before delivery it
may lead to litigation if the outcome is not
satisfactory.

What should we do?

There is no simple solution. External cephalic
version is an attractive option. However, the small
risk associated with ECV partly offsets the benefit
from elective caesarean section at term compared
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with planned vaginal breech delivery. Success rates

vary and there may be a higher incidence of
caesarean section, despite ECV being successful.23
Successful ECV does reduce the risk of caesarean
section and its subsequent sequelae and the
additional risks of cord prolapse and unexpected
breech delivery.
Elective caesarean section is probably the safest
option in terms of short-term risk for the fetus and,
from a medicolegal perspective, for the
obstetrician. In the long term, neurodevelopmental
delay may change this view. Caesarean section has
the benefit in primigravid women of sparing the
pelvic floor unless they subsequently deliver
vaginally. However, the small but real risk of scar
dehiscence and placenta praevia accreta in future
pregnancies may negate the advantages of shortterm risk to the fetus.
There is no doubt that there is a place for planned
vaginal breech delivery. However, the criteria that
have to be met with regard to selection, monitoring
and experience with breech delivery can be difficult
to achieve in many clinical settings. If the facilities
are adequate and the woman is fully informed of
the risks and benefits, this option should be offered.
If the requirements cannot be met, it would be
reasonable to refer women to a unit that can meet
them. Patient information sheets can help with
obtaining informed consent and may help to avoid
litigation if the outcome is not favourable.

Conclusion
From the information we have it seems that we
should offer elective caesarean section as the
method of choice for delivery of the term breech
presentation. This will come at the cost of a higher
number of caesarean sections and lost expertise in
vaginal breech delivery. It is inevitable that vaginal
breech deliveries will still occur. Many of these may
be in emergency situations that will be more
difficult to manage than planned term deliveries.
Training in ECV and vaginal breech delivery should
be continued, even in departments and settings
where elective caesarean section is the method of
choice for breech delivery at term. Breech deliveries
will happen!
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Gynaecologist 2002;4:97100.
29 Bolam v. Friern Hospital Management Committee (1957) 1 WLR 583.
30 Bolitho v. City and Hackney Health Authority (1997) 4 AER 771.

2007 Royal College of Obstetricians and Gynaecologists